A Smile Makeover from Start to Finish with Q & A from the Townies By: Michael Barr, DDS, Official DentalTown Townie

Before

After

Certainly, there is no shortage of articles showcasing cosmetic cases these days. However, cosmetic dentistry remains a popular topic in dental literature. A quick perusal of the Yellow Pages reveals virtually every dentist claims to provide cosmetic dentistry, and one could argue the definition of cosmetic dentistry seems rather broad. And, sadly, the public is largely unaware of the existence of today’s exquisite cosmetic dentistry.

This is yet another cosmetic case presentation. Oh, joy! I will try to focus on aspects beyond the actual clinical technique, which has been covered by many other authors. I hope some will find it interesting!

This patient is a 40-year-old mother of three (Fig. 1). She found my practice via my website (www.palmbeach-smiles.com), which is dedicated to the cosmetic side of dentistry. She lives about 20 miles away and has a “regular dentist” in her town. Her chief complaint was she was unhappy with her smile. She didn’t like the spaces between her teeth, nor did she like the shape of her teeth. She also complained that she had some crowns done in the past year that were unaesthetic and didn’t “feel right.” I asked her if she had asked her dentist about solutions to her concern. She told me she had, and that he simply referred her to an orthodontist. I asked her if she considered orthodontic treatment. She had talked to her daughter’s orthodontist, but she did not want braces. She wanted to know if there was another solution. I told her I believed I could help create the smile she wanted, but needed to evaluate her further before presenting a final treatment plan. I needed to make models, photos, bite records, and a full mouth series.

At the next visit, I performed a comprehensive examination. Upper and lower poly-vinyl impressions were made for diagnostic models. I like to use an impression material that can be poured more than once for duplicate models. The duplicate models are used for a diagnostic wax-up. A facebow and centric relations records were made for mounting on a Denar Combi articulator. Pre-operative photographs were made, as well. Clinical examination revealed worn teeth (Figs. 2–6, on following page). The patient acknowledged a bruxism habit. Typically, there are 10 teeth in the “aesthetic zone” going from 2nd premolar to 2nd premolar. Multiple large diastemata were present in the maxillary arch. The anterior 6 teeth were otherwise unremarkable with no decay or previous restorations. The crowns on teeth #s 12 and 13 were unaesthetic, were over-contoured and had open margins on the lingual. Teeth #s 4 and 5 had Class II amalgam restorations that were unaesthetic but serviceable. Her mandibular range of motion was normal with no deviation. There was no clicking or popping evident, nor was there any tenderness of the TMJs. At the end of this appointment, I briefly discussed some possible treatment plans including a combination of veneers and crowns. Orthodontic treatment was mentioned again. I felt that orthodontics would help the case, but it would not eliminate the need for additional cosmetic treatment. The patient repeated her refusal to have braces. I also mentioned that in order to achieve a cosmetic result, periodontal surgery might be required. The patient was dismissed and re-appointed for a treatment plan consultation appointment.

I believe planning is absolutely critical to outstanding and predictable results. Plan, plan, plan! Furthermore, photographs and models are key elements of the planning process. The models were mounted and the photos (slides) were processed. Photographs can often reveal details that are missed during the live patient examination. It also gives me an opportunity to objectively look at the smile and all of its components. The smile shot reveals a few things (Fig. 2). There is a moderately excessive display of gingival tissue. I can also see that simply closing the diastemata will result in teeth that have a poor width to length ratio, which is ideally around 75%. Closing the diastemata without lengthening the teeth will create short, fat teeth. However, adding any more than about 1mm would cause them to run into the lower lip and possibly cause phonetic problems. This is very important information. To create properly proportioned teeth, I will need to lengthen them in the gingival direction. This will also create a more pleasing gingival presentation. I also noticed that the lateral incisors are a bit narrow and rotated. The occlusal shot (Fig. 7) reveals the crowns on #s 12 and 13 are over-contoured bucco-lingually (compare to contralateral teeth). The porcelain had been adjusted on the occlusal surface down to the metal. This is likely due to under-preparation.

Fig. 2

Fig. 3

Fig. 4

Fig. 5

Fig. 6

Evaluation of the mounted models revealed a non-working interference on the mesio-lingual cusp of tooth #2 (to be adjusted later). She also had a fairly deep overbite in the anterior segment. I mounted the duplicate models the same way as the diagnostic models. In cases like this, I prefer to do a diagnostic wax-up myself. While my wax-ups may not be as artistic as those done by a commercial lab, I feel it helps me visualize not only the final result, but also what it will take to get there. First, I simulated the crown lengthening by carving the stone back. Then I waxed up the teeth to full contour. This verified that the case was “doable.” I then took a 3rd model and prepped the teeth as I would on the actual patient. For a case like this, I find that a “dress rehearsal” makes the actual appointment go more smoothly. I have, essentially, done a “practice run.”

The photos were scanned and placed into a PowerPoint presentation. I also had the pre-op face shot and smile shot cosmetically imaged (Dr. David Sultanov–smiledream1@aol.com) and placed into the PowerPoint presentation. The patient returned for a treatment plan consultation. I used the PowerPoint presentation on a laptop computer and showed the photos, including the imaged smile, to the patient as I discussed her various “cosmetic challenges.” I also explained the need for crown lengthening surgery. After the slide show, she requested we go ahead with the plan for crown lengthening, four crowns, and six veneers. The patient and I also perused Dr. Lorin Berland’s “Lorin Library” of smiles (www.dallasdentalspa.com). This is a very effective catalog of smiles using the same model throughout. There are a variety of incisal edge characterizations that dramatically affect the “style” of the smile. The patient chose a style that we would later use to guide the lab in creating the final restorations.

I referred the patient to a periodontist. I sent a surgical stent made from the wax-up model to guide the surgeon in creating the final gingival architecture. Did I mention planning? After 8 weeks of healing, we were ready for preparation.

The teeth were prepped. A clear stent made from the wax-up was used to verify adequate reduction. Some minor gingival recontouring was done with an electrosurge. A final impression and bite registration was made. Photos were made of the preps with “prep shade” tabs (sounds better than “stump shade”) for lab communication. Provisional restorations were made with Luxatemp (Zenith) using a Sil-Tech (Ivoclar) putty matrix made from the wax-up. The provisionals serve as another ingredient in the planning and allow the patient to preview the final result. An impression of the provisionals was made for lab communication. A color map (LVI kit) was used to describe the desired multi-chromatic shading needed to create a natural appearance.

Fig. 7

Fig. 8

Fig. 9

Fig. 10

Fig. 11

Fig. 12

The patient returned three weeks later for delivery of the final restorations. They were tried in for fit and aesthetic evaluation. The patient accepted the appearance and gave the go-ahead for cementation. The crowns were cemented first. Then the anterior six veneers were cemented simultaneously. The patient was thrilled. Because we were able to effectively communicate the shape of the final result using the Lorin Library, minimal to no recontouring was required. I feel the result is outstanding (Figs. 8–12). I was particularly pleased with the way I was able to close the diastema between #s 10 and 11 (Figs. 6 and 11). An NTI (www.nti-tss.com) nighttime appliance was made to protect the final restorations from clenching and bruxing. This patient was so happy with the result, she is planning on having the lower arch treated cosmetically in the near future.

I really enjoy this aspect of dentistry and see it as the “fun” side of my work. I feel that hands-on continuing education is vital to drastically shortening the learning curve for dentists who desire to offer this level of treatment.

Oh yeah…did I mention planning?

Dr. Michael Barr practices in Boynton Beach, Florida. He is a clinical instructor for the Rosenthal Institute’s Aesthetic Advantage hands-on program in Palm Beach, Florida. Dr. Barr would like to thank Dr. Larry Rosenthal for being instrumental in his professional evolution. He would also like to thank the outstanding team at Burbank Dental Lab for their assistance with this case. Dr. Barr can be reached at 561-736-2377 or by email at: mikebarrdds@palmbeach-smiles.com.

When Dr. Barr presented his case online, here are some of the questions immediately raised. If you would like to see all the comments on this case, or perhaps add some of your own, go to DentalTown’s home page, click on the Kodak presentation button and sign in. This case is listed under the cosmetics category as: mikebarr: Veneer Case.

glennvanas 7/14/2002 6:25:56 AM	Mike: Congrats on a very nice job with very nice proportions. It sure is nice to be able to blow up the pics and get a close-up of the teeth. Did you run the contacts through to the palatal? Do you have any views of the palatal? In my experience these cases must have the contacts brought further to the palatal to give the lab the opportunity to make the veneers flow through the contact areas interproximally properly. I like the result and her smile is super. I noticed the embrasure space on the left central (mesial aspect) is a little different shape than the others. Rounding it off a little might just give a little more symmetry but otherwise I thought everything looked beautiful and I am sure that the patient loves them. P.S. What material did you use for the veneers and in addition what material did you use to replace the crown on the left first premolar?
mikebarr 7/14/2002 7:47:24 AM	Glenn, Thanks for the comments/compliments! Empress was used for all restorations. Contacts were broken throughout. I agree on the mesio-incisal symmetry. This shows the value of photography for self-critique.
dolemite2 7/14/2002 10:25:28 AM	Hey Mike…great case. First it takes guts to put your work on the Internet, but you did a great job. The way you handled closing the space between #6 and #7 while maintaining a natural look is impressive and deserves compliment. That is a difficult thing to do. Did you do any gingival surgery on the mesial of 6 or distal of 7 to help your emergence?
Drpravir 7/16/2002 8:47:20 PM	Hi Mike. Very nice case...just curious did you go with digital pics or SLR?
mikebarr 7/17/2002 1:59:55 PM	Doley, Yes...in addition to osseous crown lengthening by a periodontist, I recontoured a little bit with electrosurge at prep time. Pravir, I took the photos with a 35mm SLR. It’s a Nikon N70, 105mm macro lens, and ringflash setup from Lester Dine. I scanned the slides (Fuji Sensia 100) with an HP PhotoSmart scanner.
cchrysler 7/22/2002 5:34:27 PM	Very nice case Mike, did the patient want the white, white look? Did you go to LVI? I am very impressed by your results given where you started. You should be proud and thanks for sharing.
mikebarr 7/22/2002 5:58:36 PM	The patient chose the basic shade. I actually used several shades and did a color map for the lab. I have not attended LVI, but I am a graduate from Larry Rosenthal’s Aesthetic Advantage hands-on course. I am also a clinical instructor for Rosenthal now when he gives his program here in Palm Beach. The next one is in February and March 2003.
Etienne 8/11/2002 1:00:35 PM	Hi Mike, Very nice work–super result!! I am looking for pictures of veneer preps, especially posterior teeth. Would you please contact me if you have any available?